In the dynamic realm of Pharmacy Benefit Manager (PBM) oversight and regulation, the recent successful reversal of discrepancies identified during an audit represents a crucial win for pharmacies defending against abusive PBM tactics. The reversals not only underscore the pharmacy's dedication to compliance and ethical practices but also exemplify the importance of engaging with experienced counsel who are well versed in the audit processes. By meticulously addressing the discrepancies uncovered during the audit, Buchanan attorneys safeguarded an independent pharmacy business against harmful audit tactics, protected patient access to care and medication, and further highlighted the need for adequate record-keeping practices. This article delves into the strategic actions taken to rectify the issues, the collaborative efforts involved, and the valuable insights gained that can inform future pharmacy operations.

100% Reversal

Recently, Buchanan’s team of Pharmacy attorneys successfully reversed 100% of audit findings identified by a major PBM, protecting the pharmacy at the center of the audit from adverse action, including, but not limited to, termination from the PBM’s pharmacy network and saving the pharmacy from facing tens of thousands of dollars in recoupment. Following the initial audit, the PBM identified a number of prescription discrepancies related to missing documentation, overbilled quantities, and copayments. These are common discrepancies that are typically identified by PBMs throughout the duration of a pharmacy audit. However, these discrepancies can be overcome when pharmacies engage in suburb recordkeeping procedures and retain experienced legal counsel familiar with contesting inflated and inaccurate audit findings. 

Contesting Audit Findings

During the audit, eighty-four (84) prescription discrepancies were identified by the reviewing PBM. However, the pharmacy denied the existence of a single discrepancy. A majority of the discrepancies were the product of the PBM having failed to adequately review the pharmacy’s records, as well as technical issues on the PBM’s end while attempting to access pharmacy documents. Regardless, the PBM handed down findings citing unwarranted discrepancies and alleging thousands of dollars owed in recoupment. Buchanan’s attorneys, being familiar with the PBM’s tactics, assessed the findings and thoroughly reviewed the pharmacy’s prescription documents to create a comprehensive appeal response detailing each of the documents needed to reverse the discrepancies and highlighting the PBMs audit deficiencies.

In addition to the discrepancies identified due to missing prescription documents, the PBM identified several overbilled quantity discrepancies. Specifically, the PBM alleged that the Pharmacy had overbilled the quantity for the claims at issue. However, the Pharmacy filled the prescriptions pursuant to manufacturer guidance and prescriber direction and maintained evidence to support the pharmacy’s billing and dispensing of such quantities. Following a review of the supporting evidence, Buchanan was able to identify key details within the documents to highlight in the pharmacy’s appeal response. In doing so, Buchanan was able to successfully reverse the remaining discrepancies and disprove the PBM’s audit findings in full.

Key Takeaways 

This successful reversal highlights the critical role of robust document management practices. By maintaining comprehensive records that include original payment methods and proof of payment, pharmacies can minimize the need for additional documentation that may be subject to increased scrutiny from PBMs. Presenting PBMs with clear, indisputable evidence of the pharmacy’s operations is an effective strategy for overturning unfavorable audit findings. Furthermore, well-organized documentation processes allow pharmacies to supply supporting evidence promptly, reducing the risk of missing crucial appeal deadlines and ensuring compliance with regulatory requirements.

How Buchanan Can Help

At Buchanan, we are dedicated to assisting independent pharmacies in tackling the intricate challenges presented by PBMs. Our team of experienced attorneys is focused on defending pharmacies against unfair PBM practices while ensuring their ongoing capability to serve their communities effectively. If your pharmacy is confronted with audit threats or other PBM-related concerns, we stand ready to help you safeguard your business and secure your future. By remaining informed, prepared, and united, independent pharmacies can effectively withstand the pressures of PBM audits and potential network terminations, thereby reinforcing their essential role within the healthcare system.

This article was co-authored by Dae Lee, Shareholder, Buchanan and Kelly Reynolds, Associate, Buchanan.